Pediatric Illness Anxiety Disorder (Formerly Hypochondriasis) 

Updated: Jan 30, 2019
Author: Maria Sandra Cely-Serrano, MD; Chief Editor: Caroly Pataki, MD 

Overview

Background

Hippocrates used the term hypochondrium in the 4th century BC to refer to the anatomic area below the ribs. Later, the term hypochondriasis emerged to refer to the ill effects upon the psyche and soma of humors or fluids that emanate from the hypochondrium and cause disease.

The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) defines hypochondriasis as the preoccupation with fears of having, or the belief that one has, a serious disease based on misinterpretation of bodily symptoms. In hypochondriasis, this preoccupation lasts at least 6 months and persists despite appropriate medical evaluation and reassurance. Hypochondriasis causes clinically significant distress or impairment in social, occupational, or other areas of functioning. These diagnostic criteria were initially described for adults, and the same basic criteria are applied to children and adolescents.

Because the literature about hypochondriasis in children and adolescents is limited, this review includes adult studies that describe the most recent advances in the subject of hypochondriasis.

Epidemiology

Frequency

United States

Hypochondriasis is rare in childhood and occurs more frequently in adolescence. The precise prevalence in children is unknown because of lack of epidemiologic studies.

As many as 69.2% of children in a psychiatric-based outpatient clinic reported somatic symptoms. More than 12% of adolescents and young adults reportedly have at least one somatoform condition during their lifetime. Somatoform disorder symptoms may begin in early childhood, and the full disorder generally emerges in people aged 8-12 years.

In adults, prevalence rates of hypochondriasis vary according to the population studied and the diagnostic interview used. A prevalence rate of 0.8% was described from a large sample in 15 centers worldwide, and a rate of 3% was described in a primary care adult sample.

Hypochondriasis was found in 7.7% of first-degree relatives of patients with hypochondriasis. These relatives also had a high rate of comorbid anxiety and depressive and other somatoform disorders. The relatives reported substantial physical and psychological impairment, including diminished work performance and disability. In addition, these relatives reported greater use of health care services but less satisfaction with that care. These relatives showed most of the same characteristics found in earlier studies of patients who are hypochondriacal.

International

In adults, prevalence rates of hypochondriasis vary according to the population studied and the diagnostic interview used. A prevalence rate of 0.8% was described from a large sample in 15 centers worldwide.

An epidemiologic German study conducted in 2007 revealed a 0.4 % prevalence rate of DSM IV hypochondriasis.[1]

Race

Hypochondriasis exhibits no racial predilection.

Sex

Musculoskeletal pain is associated with depression in both girls and boys. Some data suggest that somatic symptoms are strongly associated with emotional disorders in girls and occur with increased frequency in boys with disruptive behavior disorders. For girls, musculoskeletal pain or the combination of stomachache and headache is associated with anxiety and depressive disorder. For boys, stomachache is associated with oppositional defiant disorder and with attention deficit hyperactivity disorder (ADHD). These data may reflect a degree of referral bias because more boys are referred for psychiatric evaluation for disruptive behavior disorders symptoms than are girls for their more common internalizing symptoms.

Age

Hypochondriasis can begin in people of any age; the most common age at onset is thought to be early adulthood. The clinician should consider a diagnosis of hypochondriasis in older teenagers who have a history of prolonged preoccupation with having a serious illness.

 

Presentation

History

The key feature of hypochondriasis is abnormal concern that one is developing or has a serious illness. These persons may not claim particular symptoms but are often preoccupied with health and avoiding germs. They may focus excessively on minor bodily signs and are most troubled by their tendency to believe that these signs imply development of a severe condition. Despite of their concerns about having illnesses undiagnosed by physicians, these patients do not tend to show typical anxiety nor do they seem to have poor health despite excessive use of health remedies. They seem to overinterpret bodily signs and are not relieved by reassurances that they are healthy. Patients with hypochondriasis believe good health is defined as a relatively symptom-free state.

The onset of hypochondriasis can occur in people of any age and is associated with dissatisfaction with medical care, doctor shopping, and deteriorating interpersonal relationships. Hypochondriasis can occur as an independent disorder, considered primary hypochondriasis, or as secondary hypochondriasis when it is part of another underlying psychiatric disorder (eg, depression, anxiety disorder).

Children with a somatization disorder have heightened risk for psychiatric disorders, family dysfunction, functional impairment, and frequent use of health services. Headache is the most frequent somatic symptom, occurring in 50% of affected children and adolescents. Younger children show higher rates of abdominal symptoms than adolescents. A nonclinical sample of students reporting frequent headaches also reported additional symptoms of somatization, as well as depression and anxiety.[2]

Children with depression or anxiety report significantly higher rates of somatic symptoms (eg, headache) than children with other mental disorders. Unexplained somatic symptoms can indicate an undiagnosed anxiety or depressive disorder. Multiple somatic symptoms are associated with anxiety, lowered self-esteem, family conflicts, health problems, and obesity. Data also suggest that higher levels of family stressors and parental somatic symptoms predict higher levels of somatic symptoms in children.[3, 4]

Patients with hypochondriasis believe good health to be relatively symptom free and consider more symptoms indicative of sickness. This may contribute to some of the clinical features of hypochondriasis, including the numerous somatic symptoms, bodily preoccupation, resistance to reassurance, and pursuit of medical care.

Assessment aims include the following:

  • Determine that no other disorder, either physical or psychiatric, better accounts for the symptoms.

  • Establish a thorough account of the psychopathology and arrive at a psychological formulation of the problem. Determination of the most suitable mental health intervention for the patient is also necessary.

  • Initiate a successful therapeutic relationship with the patient. The patient should feel that an empathic and competent therapist conducted the assessment in a satisfactory and complete manner.

Assessment should elicit the following information from the patient:

  • A brief description (ie, history) of the problem, including onset, severity, and duration

  • Triggers, both internal and external

  • Mood state, particularly anxiety and depression

  • Effects of the problem on school, work, or both and on social relationships

  • Medical interventions and how the interventions were interpreted by the patient

  • Previous treatment and reason, if any, of failure

  • Previous episodes of health concern

  • History of physical illness in the patient or a relative or friend

  • Patient's expectation of treatment

  • Cognitive factors

    • Thoughts, images, or both that trigger health anxiety

    • Intrusive negative thoughts, images, or both

    • Evidence for faulty beliefs

    • Dysfunctional assumptions

    • Selective attention or memory for information about health

    • Preoccupation with health or illness

    • Increased body focus

  • Behavioral factors

    • Behaviors that trigger health anxiety

    • Abnormal illness behaviors (eg, checking, avoidance, reassurance-seeking

  • Physiologic factors

    • Physical symptoms that trigger health anxiety

    • Physical symptoms of anxiety

    • Physical symptoms caused by increased bodily focus and repetitive body checking

Assessment should include information from other sources such as relatives, medical records, and involved professionals. Assessment measures include the following:

  • Diaries of intrusive negative thoughts

  • Diaries of physical symptoms

  • Baseline ratings of health anxiety, need for reassurance, and disease conviction

  • Standardized questionnaires (eg, Illness Behavior Questionnaire, Illness Attitude Questionnaire)

The Multidimensional Inventory of Hypochondrial Traits (MITH) was developed as a 4-component instrument consisting of affective, cognitive, behavioral, and perceptual scales, which reliably and validly measures hypochondriasis. The MITH was developed for research and is not intended as a diagnostic instrument. This tool is the first attempt to build a differentiated model of hypochondriasis and to construct a valid measure based on the model. This tool was developed primary with adult patients. The correlated 4-factor model provides a coherent theoretical foundation upon which future research can be built.[5]

Functional somatic symptoms (FSSs) in children aged 5-7 years were studied and published in 2012. The study validates FSSs clinically and describes the classification and a number of conditions that many times are not applicable to young children.[6]

Causes

Different theories help explain the origin of somatoform disorders such as hypochondriasis.

  • Biologic causes: Genetic or familial factors play a significant role in predisposing an individual to somatoform disorders. These disorders may be associated with the following characteristics:

    • Low pain threshold

    • Impaired verbal communication

    • Patterns of information processing characterized by distractibility, impulsiveness, and failure to habituate to repetitive stimuli

  • Psychodynamic theories: These theories explain that an unconscious intrapsychic conflict, wish, or need is converted into somatic symptoms that symbolically express some aspect of the conflict and, at the same time, protect the individual from conscious awareness of it. By keeping the wish unconscious, the symptom minimizes anxiety and thus provides primary gain. A secondary gain is that the symptom provides an escape from unwanted consequences or responsibilities.

  • Trauma and abuse: According to some studies, an association among childhood physical or sexual abuse and conversion, somatization, and dissociative disorders is observed.[7]

  • Learning theory: A child with an injury or illness quickly learns the benefits of the sick role and may be reluctant to recover. Symptoms are reinforced by increased parental attention and avoidance of unpleasant responsibilities (eg, attending school). Having a role model in the family for the illness has been correlated with somatoform disorders.

  • Emotion and communication

    • Children who have difficulty expressing emotions verbally use symptoms to communicate distress.

    • High-achieving children who try to meet parental expectations may be unable to admit to themselves or to their parents that they are under too much pressure.

    • Physical symptoms may be used to express emotions in families in which overt emotional expression is discouraged.

    • Anxious or depressed children may express somatic symptoms to express their feelings.

  • Family systems: In this theory, somatization is initiated by specific family patterns; the child's symptoms maintain homeostasis in the family. The family may display the following 4 characteristic patterns:

    • Enmeshment or blurring of interpersonal boundaries

    • Overprotection, demonstrated as limiting the child's involvement in age-appropriate activities

    • Rigidity, demonstrated by difficulty with life transition events (eg, puberty)

    • Lack of conflict resolution because of aversion to conflict and finding ways to avoid points of disagreement

  • Environmental and social influences: Cultural factors influence the tendency to somatize and the choice of symptoms. In some cultures, somatic symptoms often are the initial symptoms for underlying anxiety or depressive disorders.

  • Interpersonal model: There is a growing literature that links childhood adversity to adult hypochondriasis. Noyes et al (2002) found in an adult study that hypochondrial patients more frequently report more traumatic events and substance abuse in the family members compared to controls.[8] In addition, parental overconcern about child's health was positively correlated with adult hypochondriasis, and maternal care was negatively correlated with somatic symptoms.

  • Association with other disorders: In an experimental analysis of hypochondriasis, subjects were exposed to personally relevant health-related stimuli under one of two conditions: (1) subsequently performing safety-checking behaviors or (2) subsequently being instructed not to perform such behaviors.[9] For subjects who performed safety-checking behaviors, feelings of anxiety were reduced. For patients who did not, a more gradual reduction of anxiety and urges was observed. These findings are relevant to hypochondriasis possible relationship to panic disorder and obsessive compulsive disorder.[10]

  • The restrictive concept of good health and misinterpretation of bodily symptoms as a sign of illness are highly specific characteristics of hypochondriasis.[11, 12]

  • Hypochondriacal attitudes may reflect a general cognitive bias that is not limited to illness-related thoughts. Three cognitive processes have been considered: a pessimistic interpretation style, reduced ratings of familiarity, and a reduced positive appraisal of familiar stimuli. In general, a less positive appraisal of familiar experiences, which is unrelated to illness-related thoughts, may maintain hypochondrial concerns. A general distrustful attitude towards familiar procedures should be considered in hypochondriasis.

  • The term cyberchondriasis has been introduced to describe that searching for health information online may exacerbate health anxiety.[13]

 

DDx

Diagnostic Considerations

The differential diagnosis of somatoform disorders and hypochondriasis should consider any possible medical or psychiatric illness. Somatoform disorders or hypochondriasis can occur concurrently with medical or psychiatric illnesses. Also, according to the DSM-IV, psychological factors affecting a medical condition imply the presence of a general medical illness.

Medical Illnesses

Patients with medical conditions with an insidious or long-term progression (eg, multiple sclerosis, hemiplegic migraine) may present with a somatoform disorder. These medical conditions have repeated, nonspecific signs and symptoms that could be interpreted as a somatoform disorder. In hemiplegic migraine, patients present with hemiplegia or hemiparesis, with or without a speech and/or language disturbance, which clears in minutes to hours. Diagnosis can be made with repeated, stereotyped episodes and complete clearing between episodes, particularly in the presence of a positive family history. In multiple sclerosis, patients have multiple symptoms that are difficult to describe initially, but the symptoms resolve subsequently. The symptoms affect different parts of the body at different times.

Patients with organic brain disorders, such as delirium or dementia of any etiology (eg, toxic, metabolic, infectious), can present with somatic symptoms.

Psychiatric Illnesses

Other somatoform disorders

Conversion disorder is the presence of symptoms or deficits in sensory or motor function that indicate an organic medical or neurologic disorder, apparently due to stress or psychological issues. Symptoms are nonintentional and have no evident pathophysiology. Most frequent symptoms are neurologic in origin (eg, blindness, seizures, paralysis, seizures).

Pain disorder is the presence of pain with no explainable etiology; the 2 types are (1) predominant psychological pain and (2) a combination of psychological factors with a medical condition.

Body dysmorphic disorder is an imagined structural defect in a person who appears normal to the expert observer.

Affective disorders

Patients with depression or mania can present with multiple symptoms such as change of appetite and sleep patterns. Depression and hypochondriasis may overlap, especially when the morbid ideation of depression takes the form of disease phobias.

Anxiety disorders

The most common symptoms in children with anxiety disorder are headaches, stomachaches, nausea, and vomiting. Symptoms are often associated with an anxiety-provoking situation.

Hypochondriasis and panic disorder are both characterized by prevalent health anxieties and illness beliefs. Panic patients have more comorbidity with agoraphobia while hypochondriac patients are more closely associated with somatization. Patients with hypochondriasis plus panic have higher levels of anxiety, more somatization, more general psychopathology, and a trend towards increased health care utilization.

Psychoses

Psychosis can be differentiated by involvement of thought processes, social withdrawal, and impaired functioning.

Obsessive-compulsive disorders

Patients with obsessive-compulsive disorder and/or hypochondriasis often share the comorbidity of intense fears of illness, injury, or contamination. The lifetime prevalence of obsessive-compulsive disorders in a series of adult patients with hypochondriasis was 4 times more than in a comparison group (ie, 8% versus 2%). In contrast to those with hypochondriasis, patients with obsessive-compulsive disorder view their fears as abnormal, attempt to suppress them, and avoid publicizing their symptoms, which are frequently observed as shameful.

Personality disorders

A high prevalence of personality disorders is noted in patients with hypochondriasis, particularly obsessive compulsive disorder (OCD). In one study, 76.5% from a total of 88 patients with hypochondriasis had OCD.[14] This suggests that consideration of personality features is important in assessment and therapeutic interventions for hypochondriasis.

Malingering and Factitious Disorders

Malingering is the intentional production of symptoms or signs of illness or disability in order to obtain a specific goal (eg, avoiding school, acquiring drugs or money).

Factitious disorder is the intentional production of symptoms to maintain a nonspecific patient role (eg, maintaining a dependency role in the family over time).

In somatoform disorders, symptoms are not produced voluntarily, thus differing from factitious disorders and malingering in which symptoms are produced intentionally.

Adolescents who present with unexplained neurologic symptoms in the primary care setting may be suffering from a clinically significant behavioral health disorder or some other form of psychological distress. If no adequate medical cause can be found to explain the patient's presenting symptomatology, it is important for the primary care provider to conduct a careful assessment of the patient's psychosocial functioning.

 

Workup

Laboratory Studies

See the list below:

  • Patients with hypochondriasis often seek exhaustive batteries of tests, which are often excessive relative to their symptoms. The diagnosis of somatoform disorder should not be a diagnosis of exclusion. Rather, the diagnosis should be based on the following positive findings: clear evidence that normal function is possible and a positive history of psychosocial stress, intrapsychic conflict, or both.

  • A thorough physical examination is indicated to rule out any pertinent medical conditions, along with a mental status examination and a psychosocial history.

 

Treatment

Medical Care

The goal of treatment is to aid the patient in managing the fear of serious illness and to help the patient to establish a greater sense of control in managing symptoms that remain. Appropriate education and a supportive relationship with a competent health care provider is the most important aspect of treatment.

Maintain regularly scheduled appointments to review symptoms and evaluate the person's coping mechanisms. At these appointments, acknowledge and explain test results. Merely making the diagnosis and linking it to psychological stressors can often be therapeutic. Telling people with this disorder that their symptoms are imaginary is not helpful. Mental health treatment can involve a variety of modalities (eg, individual psychotherapy, family therapy, group therapy, parent guidance).

  • Individual psychotherapy can use psychodynamic principles to help the child understand unconscious conflicts.

  • Eliminate sources of secondary gain.

  • Cognitive and behavioral approaches can be helpful and may prove to be the therapy of choice.[15] Behavior modification provides incentives, motivation, and rewards to control the symptoms.

    • In adults brief (6 session), individual cognitive behavioral therapy intervention developed specifically to alter hypochondriacal thinking and restructure hypochondriacal beliefs appears to have significant beneficial long-term effects on the symptoms of hypochondriasis.

    • In one adult study, cognitive behavioral therapy and paroxetine were effective short-term treatment for subjects with hypochondriasis.[16] Results from the combined therapy were significantly superior to placebo but did not significantly differ from the results of the individual therapies.

    • A meta-analysis of effectiveness of psychotherapies for hypochondriasis revealed that cognitive therapy, behavioral therapy, cognitive behavioral therapy, and behavioral stress management are effective in reducing the symptoms of hypochondriasis.[17] However, studies included in the review used a small number of participants and did not allow for the estimation of effect size.[18]

  • Family therapy focuses on awareness of familiar patterns of interaction and attempts to improve healthy interpersonal communication.

  • Group therapy provides support to learn how to cope with the symptoms and to learn strategies to improve social skills.[19]

  • Education about the links between a person's psychological and physical states should be provided to the child and his or her parents or caregivers.

  • Development of coping skills, including relaxation techniques, cognitive restructuring, and refocusing, is helpful.

  • Involvement of school personnel and those in other social settings frequented by the child is helpful.

Studies in adults comparing cognitive behavioral therapy (CBT) with short-term psychodynamic psychotherapy (STPP) and no intervention for patients with hypochondriasis suggests that CBT is more effective than STPP in the treatment of hypochondriasis.[20, 21, 22]

Long-term follow-up studies in adults who received selective serotonin reuptake inhibitor (SSRIs) treatment suggest that patients with hypochondriasis who receive treatment with SSRIs achieve remission over long term and interim use may be a factor contributing to better prognosis.[23]

 

Medication

Medication Summary

A review of somatoform disorder management in several adult psychiatric consultation-liaison services showed that recommendations were made for antidepressants in 40% of the patients, anxiolytics in 18%, sedatives in 18%, and antipsychotics in 10%. Pharmacologic management was consistent with comorbid psychiatric diagnoses of mood disorder in 39% of patients, of personality disorder in 37%, and of psychoactive substance use disorder in 19%.

Selective serotonin reuptake inhibitors (SSRIs)

Class Summary

SSRIs are chemically unrelated to the tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT). They may also have a weak effect on norepinephrine and dopamine neuronal reuptake. They have also been used to treat anxiety, phobias, and obsessive-compulsive disorders. Growing evidence suggests the efficacy of SSRIs to treat hypochondriasis. Although controlled adult trials using fluoxetine revealed a high rate of improvement, many patients responded as well to a placebo. Medication has been particularly helpful when comorbid conditions (eg, anxiety disorder, depression) are associated with hypochondriasis.

SSRIs are greatly preferred over the other classes of antidepressants. Because the adverse effect profile of SSRIs is less prominent, improved compliance is promoted. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with mood disorder.

Physicians are advised to be aware of the following information and use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, one study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.[24] This is the largest study to date to address this issue.

Currently, evidence does not associate obsessive compulsive disorder and other anxiety disorders treated with SSRIs with an increased risk of suicide. For more information, see the FDA Web site on Antidepressant Use in Children, Adolescents, and Adults.

Fluoxetine (Prozac)

Selectively inhibits presynaptic serotonin reuptake with minimal or no effect on reuptake of norepinephrine or dopamine.

 

Follow-up

Further Outpatient Care

See the list below:

  • See Medical Care for information about ongoing treatment in patients with hypochondriasis.

Complications

See the list below:

  • The primary health care provider may overlook an actual medical illness present in an individual with a somatoform disorder because of their history of unfounded symptoms.

  • Complications may result from invasive testing and multiple evaluations employed in the search for the cause of the symptoms. Patients also incur unnecessary hospitalizations, diagnostic tests, medication trials, and surgical procedures.

  • Dependency on pain relievers or sedatives may develop.

  • A poor relationship with the health care provider or evaluation by many providers seems to worsen hypochondriasis.

Prognosis

See the list below:

  • People with somatoform disorders rarely acknowledge that their illness has a psychological component and usually reject mental health treatment.

Patient Education

See the list below:

  • Mental health screening for children and adolescents with persistent reports of headaches, stomachaches, or musculoskeletal pains helps identify and manage somatoform disorders.

  • Psychoeducation always helps manage cases of somatoform disorders. The cost-effectiveness of educational approaches makes them a first-line intervention.